1. Field
This invention relates generally to the field of computerized systems for storing and creating electronic records, and in particular to methods and systems for creating medical documentation regarding a patient.
2. Description of Related Art
In the medical arena, hand written patient record keeping systems have evolved through many years of careful refinement and enhancement into systems which maintain a detailed manual record of medical information concerning each patient. To meet the needs of different hospital entities (such as doctors, nurses, pharmacy, accounting, laboratory, etc.) a manual record keeping system often requires that one piece of information be entered into multiple records. In addition it often requires that the same information that has not changed from visit to visit (such as family/social history, allergies, immunization status) be re-asked of the patient and re-documented in the current record. In certain instances, such as in the Emergency Department, this information may be asked and recorded as many as three separate times (on the Triage Note; the main ED record; and MD documentation) leaving the patient to wonder if there is any communication between healthcare providers and frustrating those healthcare providers who must fill out more and more paperwork. If the patient is admitted, this same information is then asked and recorded again by the admitting nurse and attending physician.
In a typical manual patient record keeping system a patient chart, usually in the form of a notebook, is maintained at the nursing station for each patient. The notebook is divided into a plurality of individual tabbed sections, such as Physicians Orders, Kardex, Nursing Care Plan, Nursing Assessment, and Laboratory.
Each of the above sections is further subdivided into a number of forms. The forms are those which are appropriate to the individual patient and/or such patient's physician. For example, within the Laboratory section there may appear forms for chemistry, hematology, blood gas, and microbiology.
In addition, a “flowsheet” chart is usually kept at the patient's bedside, particularly in a critical care environment. On the “flowsheet” chart there are individual areas for medication records, vital signs, intake/output, laboratory results, and other categories which are dependent upon the patient's affliction, such as intravenous (IV) drips.
Referring in particular to nursing functions, annotations to charts and/or nursing progress notes are made manually. Typically, brief notations are jotted down in various places through-out a shift. Sometime during the shift, typically at the end, the nurse makes a full notation into the nursing progress notes based on the brief notations or remembered items. This process can be very inefficient since notations may be forgotten or not copied appropriately. In particular, documentation and entry of physician orders, prescriptions and other activity has been viewed as two separate activities or steps, one step completing the documentation and a second step of entry of the order or prescription in the medical records of the patient.
The need for more efficiency of workflow and coordination between multiple departments and healthcare providers in a hospital environment has led to the advent of computerized medical records applications. Medical records management systems are known in the art and include the systems disclosed in the following U.S. Pat. Nos. 5,325,478; 5,247,611; 5,077,666; 5,072,383 and 5,253,362 all assigned to the assignee of this invention, and have been commercialized by the Assignee of this invention and others. Other background prior art of interest includes Cantlin et al., US 2006/0173858; Kim et al. U.S. Pat. No. 7,793,217; Britton et al. U.S. 2004/0015778 and Goede et al. U.S. Pat. No. 7,453,472.
Some software applications for creating medical documentation require a user to type in textual entries representing observations of a patient. Often, such observations may encompass complex medical concepts. As one example, in the context of a examination of a cardiac patient, the observations may include observations about particular heart murmur patterns present in the aortic, tricuspid, mitral and pulmonary valves. Medical documentation (e.g., a structured note) is created by the physician that documents all such observations. A text-based approach to creating such documentation (i.e., typing in all of the clinical observations) is time consuming and inefficient.